Patient: [Patient Name] MRN: [Medical Record Number] Date: [Date of Visit]
Chief Complaint:
Document the patient’s main concerns related to their immersion foot syndrome (IFS). This may include:
Pain (burning, throbbing, tingling) in the feet and toes
Numbness or weakness in the feet and toes
Skin changes (wrinkling, blisters, peeling)
Difficulty walking or standing
History of Present Illness:
Duration of symptoms
Activities leading to prolonged immersion (e.g., wearing wet shoes/boots, occupational exposure)
Progression of symptoms (worsening, improvement)
Any recent changes in sensation, skin appearance, or ability to walk
Past Medical History:
Underlying medical conditions that can worsen IFS (e.g., diabetes, peripheral vascular disease)
History of previous foot problems (e.rench foot, fungal infections)
Current medications (especially those affecting circulation)
Social History:
Occupation and potential for wet working conditions
Footwear habits (wearing wet shoes for prolonged periods)
History of smoking (constricts blood vessels and worsens IFS)
Physical Examination:
Vital signs (may be normal or show signs of infection)
Skin examination of the feet and toes:
Color changes (redness, pallor)
Blistering
Skin breakdown/ulceration
Presence of excessive moisture
Peripheral pulses (dorsalis pedis and posterior tibial) – assess for vascular sufficiency
Sensation testing (light touch, pinprick) – assess for nerve involvement
Motor function (foot strength, ability to walk on heels and toes)
Imaging Studies (if indicated):
X-ray (to rule out fractures or osteomyelitis)
Doppler ultrasound (to assess blood flow in the legs)
Diagnosis:
Specify the type of immersion foot syndrome:
Immersion foot (mildest form, with skin changes and mild discomfort)
Trench foot (more severe, with deeper tissue involvement, pain, and potential for nerve damage)
Immersion foot syndrome with superimposed infection (if present)
Treatment Plan:
Foot Care:
Elevation and rest
Thorough drying of the feet and toes
Frequent skin checks for moisture and breakdown
Topical antifungal medications (if fungal infection present)
Appropriate wound care (if skin breakdown occurs)
Pain Management:
Over-the-counter pain relievers (e.g., acetaminophen, ibuprofen)
Topical pain medications (consider benefits vs. risks)
Vascular Insufficiency (if present):
Elevation and compression stockings to improve circulation
Vasodilator medications (to be prescribed by a doctor)
Antibiotics (if infection is present):
Based on culture results and physician discretion
Prognosis:
Discuss the outlook based on the severity of IFS, presence of infection, and underlying medical conditions.
Early diagnosis and treatment lead to better outcomes and faster recovery.
Residual nerve damage or chronic pain may occur in severe cases.
Education and Follow-up:
Educate the patient on proper foot care practices to prevent recurrence.
Emphasize the importance of dry footwear and avoiding prolonged immersion.
Schedule follow-up appointments to monitor healing and address any complications.
Advise seeking immediate medical attention if signs of infection develop (increased pain, redness, pus drainage).
Additional Notes:
Document any limitations in weight-bearing or ambulation due to IFS.
Consider referral to physical or occupational therapy for gait training or wound care education (if needed).